A Perspective with Howard K. Rabinowitz, M.D., the head of the Physician Shortage Area Program at Thomas Jefferson University in Philadelphia, and the author of Caring for the Country: Family Doctors in Small Rural Towns

1. Much of your work is devoted to the rural community: what prompted you to focus on this part of society?

The rural physician shortage is a huge problem - 20% of Americans live in rural areas, and almost 20 million Americans live in a rural federally designated primary care physician shortage area - that's 1/2 the number who are uninsured in this country. So the problem is huge - and its been around for almost 100 years.

Although I have lived in urban areas for most of my life, the 2 years I spent on the Pima Indian Reservation in the southern Arizona desert was the first time I recognized the unique challenges and joys of working in an area of small population.

After joining the Department of Family Medicine at Jefferson Medical College of Thomas Jefferson University in Philadelphia, I was asked to be responsible for a new program--the Physician Shortage Area Program (PSAP)--which trains individuals who grew up in rural areas and are committed to practice the specialty of family medicine in a similar area. Over the past 28 years directing this program, I have learned even more from my students and our outcomes research.

2. What were your hopes in writing your recent book, Caring for the Country?

With the support of the Robert Wood Johnson Foundation, I wrote Caring for the Country to share with others what rural family practice was like. Over the years, it became obvious that there is an enormous number of myths about rural practice, mostly from individuals who had little first hand experience. So I decided the best way to share what it was really like would be to visit 10 of my former students--all graduates of our program--who were practicing rural family medicine. My hope is that this book will provide a realistic perspective of rural practice, and stimulate others to consider a career practicing in a rural area or small town.

3. Many people have impressions of country doctors as being outdated. Where do you think this impression came from? What are their jobs really like today?

There is a myth that only those doctors in the most advanced tertiary care teaching hospitals in the country are 'up to date.' The cohort of recently trained physicians have been very well trained and--no matter where they practice--are required to keep up with the latest advances in medicine in order to maintain certification. The 10 doctors whom I interviewed and shadowed practiced extremely high quality medical care, and most people would be extremely satisfied if they were cared for in this way. These country doctors today have a broader scope of practice than their urban peers have - which they find very appealing as they are able to utilize and practice what they have been trained to do. In addition, they have a rich and treasured relationship with their patients - who they not only care for, but also live with in their community. Finally, these rural physicians have fewer problems and complaints about these issues than their urban counterparts - there is less 'managed care', lower malpractice insurance cost, etc.

4. What are the most common medical issues that family practitioners in rural communities face?

The medical issues most family doctors face are similar to those of urban doctors, with the exception of things like farm related illnesses and accidents. But people everywhere have similar medical problems that occur commonly, including high blood pressure, diabetes, depression, arthritis, infections, cancer, etc. But because of the greater scope of practice, more rural family doctors are also more likely to incorporate other things into their practice, like delivering babies and office surgical procedures such as removing skin lesions.

5. What issues, other than medical issues, do doctors in rural areas have to deal with?

Like all doctors, rural physicians deal with a wide range of personal and social problems that affect people, including issues related to family problems, divorce, and alcohol and drug abuse. In rural areas, physicians also tend to become active in community leadership activities. Of the 10 doctors in the book, one was on Borough Council, one was on the Board of a local bank, and one was involved in community development.

6. On average, to how wide a physical area does the scope of the practice for a rural doctor extend? Do the patients travel to the physician or does he or she travel to them?

That depends on the area of the country. In the east, it tends to be smaller, in the range of a county or about 30-50 miles. In the Midwest and the West, where there is more land and people live farther apart, this can extend over a much larger area. While rural doctors do tend to make some house calls, most care is delivered in the office and hospital.

7. What is the most rewarding experience for physicians practicing medicine in a rural patient care setting?

The 10 doctors in the book clearly relate that their greatest rewards are related to their relationships with their patients.

8. What are some of the primary reasons that are keeping physicians from practicing or staying in rural areas? What is keeping America's number of rural doctors so low?

Most physicians prefer to live in urban and suburban areas. In addition, training physicians in tertiary care settings helps make them dependent on these facilities, and they feel uncomfortable leaving their confines. There are lots of reasons why America has a shortage of rural physicians, but some of the major reasons relate to the lack of rural-raised students who go to medical school, the lack of rural role models that medical students see, and the lack of rural experiences they encounter.

While the myth is that rural physicians earn less than urban doctors, recent data shows that this is not true. In fact, considering the lower living expenses, rural doctors actually have a higher standard of living than their urban peers. In addition, while rural doctors tend to work about 5 hours per week longer, urban doctors spend an equal amount of time commuting.

9. How much support do doctors in rural areas receive? Do doctors tend to practice alone?

Some rural doctors still practice by themselves, but almost all newly trained doctors join a group or are part of a call network to share nightcall and responsibility.

10. What is the biggest challenge in the future of rural medicine? How can future doctors meet this challenge?

As with all of medicine, there are many challenges. For rural medicine, the biggest challenge is getting enough physicians to experience and learn about rural practice to see if they are interested in it.

Serene Chen is a writer with the Next Generation and a member of the Harvard College Class of 2008.